Anastomotic stenosis of the descending colon caused by barium granuloma formation following barium peritonitis: report of a case

Abstract

Anastomotic stricture reportedly often recurs following barium peritonitis, regardless of whether the anastomotic diameter is initially sufficient. However, the causes of repetitive stricture have not been clarified. We report a case that suggests the pathophysiology of recurrent anastomotic strictures following barium peritonitis. The patient was a 39-year-old Japanese man with idiopathic perforation of the descending colon after undergoing an upper gastrointestinal barium contrast study. After emergency peritoneal lavage and diverting colostomy, created using the perforated region, the patient recovered uneventfully and 3 months later, the colostomy was closed and the perforated colon was resected. However, 7 months after colostomy closure, abdominal distention gradually developed, and colonoscopy revealed an anastomotic stricture. The patient was referred to our hospital where he underwent resection of the anastomotic stricture. The surgical specimen exhibited barium granulomas not only in the subserosa of the entire specimen, but also in the submucosa and lamina propria localized in the anastomotic site. These findings suggest that barium was embedded in the submucosa and lamina propria with manipulation of the stapled anastomosis and that the barium trapped in the anastomotic site caused persistent inflammation, resulting in an anastomotic stricture.

Fig. 1

a Radiography, b gastrografin enema examination, and c computed tomography (CT) revealed stenosis of the descending colon (arrows) and remarkable distention on the oral side of the descending colon. Barium nodules were detected in the peritoneal cavity, especially near the anastomosis

Fig. 2

Several whitish nodules of barium were found in the abdominal cavity (arrows), firmly adhered to the bowel wall

Fig. 3

a The surgical specimen exhibited pinhole colon stenosis in the anastomosis. b Fibrosis was observed not only in the subserosa, but also in the submucosa and muscularis propria (arrow)

Fig. 4

a Barium granulomas were present in the serosa. b Barium crystals were englobed by macrophages and multinucleated foreign body giant cells. This finding led to the diagnosis of barium granulomas. c The crystals were negatively birefringent, compatible with barium sulfate. d, e Barium granulomas were present in the submucosa and lamina propria, localized in the anastomosis (arrows)